Eclectic Psychiatry and random jottings

Social Justice Warfare and Mental Health

If your ambition is to rescue people from oppression and misery, then mental health is a good place to start.

People with poor mental health struggle to find employment

They die younger…

…and the gap does not diminish as longevity advances generally, even in the most supportive societies.

They’re more likely to be homeless…

…been maltreated

…and that continues through their lives

Of course, these discoveries about mental health could only be made because people had ways of telling the difference between good and bad mental health in the first place. This difference is codified in either diagnostic criteria or questionnaire cut-offs, and judicious use of either (or sometimes both) is pretty good at identifying people with difficulties in their mental health.

Now consider this

The idea that diagnosis identifies mental disorders which may become objects of study has created theoretical and practical divisions between ‘normal’ and ‘abnormal’ which have hindered understanding of behaviour and experience in general – not just that said to be symptomatic of mental illness. Abandoning diagnosis is therefore an important step in practising what we preach – in creating a unified approach to our subject.

This is part of a position statement in UK Clinical Psychology. My previous blogs on this site explain, at some length, why I think this is mistaken in principle. Here, I’ll merely point out that without any ability to identify the mentally unwell, none of the statistics which justify interventions, and can measure improvement would have been collectible. As this statement has been made by people who have dedicated their working lives to helping this group, something must be seriously amiss. It’s time to meet

The Social Justice Demon

Lucifer: according to Milton, the first social justice warrior

Social Justice sounds so good that it’s tempting to agree with it without further ado. It also has a long and honourable history going back to Augustine of Hippo, who argued that justice was the yardstick by which states could measure their legitimacy. Its most important recent proponent, John Rawls, both defined it and extended it to all justice using the concept of “justice as fairness“. Unpacking this apparently simple definition eventually required an awful lot of words

which expand on a few basic principles

The original position

Imagine we get together to agree on a society. If everyone is to receive fair treatment, it follows that they should not know of their own personal characteristics or position in society when deciding its rules, to avoid bias in rule selection. Rawls called this “the original position”, and saw it as the first principle to be fulfilled, his view being that fair rules could not be decided otherwise. He called the state of mind associated with the original position “the veil of ignorance”.

The difference principle

If, like Rawls, we accept that there has to be some difference in society’s roles and rewards, then the veil of ignorance means we don’t know whether we are going to be winners or losers when we agree society’s rules. It is therefore no more than prudence to propose that society’s differences should be arranged so that the poorest and weakest are protected from adverse effects of the differences we accept.

Principle of equality of opportunity

By the same kind of reasoning, to avoid keeping ourselves from the roles that would most benefit ourselves in our society, the opportunity to attain these roles must be equally available for all.

Rawls saw these principles as fundamental to liberal and social democracies, and most folks agree with him. After all, what’s not to like?

Given that we are currently in the land of pure principle and fluffy bunnies, it’s not surprising that we have to be positively demonic to see what could possibly go wrong

When Lucifer demanded equal rights for angels

It is striking that the sentiments Milton gave Lucifer were very similar to those that we’ve just heard from Rawls, and probably account for some of the sympathy we feel towards him when we read Paradise Lost. In a society which insisted reason was ultimately bounded by revelation (and the authorities which claimed the right to interpret it), this is obviously good propaganda. However. revelation has been replaced by law as the justification for our society, and following Rawls, this is conceived as a form of social contract. As we can no longer turn to an omniscient God to rescue us, let’s think about what happens when Rawls’ principles hit the real world.

The real world is an uncomfortable place for pure principle

Our precious veil of ignorance gets replaced by a veil of approximate knowledge, whose reliability varies according to topic. We have absolutely no guarantee that the rules we make will have the results we desire. Physical realities such as distance and time, as well as societal decisions, impinge on equality of opportunity.

If we try to get back to Rawls’ original position from here, we end up with the first rule of the social justice demon

True justice is based on refuting difference

What this does is to reverse the direction of Rawls’ veil of ignorance. If Rawls said “if we have a veil of ignorance then we may have justice” this claims “if we are to have justice then we need a veil of ignorance.” Unlike Rawls, who only used the original position as a rational basis for his other principles, this goes against the basic conception that Justice is about treating equal things equally and unequal things unequally, as we are now seeking the same implementation of rules for different things, rather than simply designing rules to fairly cover all possible circumstances. This leads to the second demonic rule

If people experience different degrees of benefit in their lives, then unfairness has occurred

This is the exact reverse of Rawls’ difference principle, which specifically allows for differences in benefit, according to what people do in practice. Of course, if we retain ignorance of what people are doing differently in relation to our benefit assessment, then equality of benefit is the inevitable consequence. A similar reversal occurs with the third demonic rule, which is

Opportunity should be regulated to ensure equality of benefit.

This of course arises because inequality of benefit has already been declared unfair. Though the implementation will look superficially like positive discrimination, it is different, because the target is not prior inequality of opportunity, but inequality of benefit.

Politically, the social justice demon belongs to the Left, just as the Nazi demon belongs to the Right…

Pol Pot giving voice to the social justice demon “only several thousand Kampucheans might have died due to some mistakes in implementing our policy of providing an affluent life for the people”

…but its relationship to socialism is like that of lung cancer to the organ. If we think of the classic socialist quote

“From each according to his ability, to each according to his needs”

It’s clear that evaluation of personal differences, including abilities and needs, are at the heart of this statement, which disappear when we consider its monstrous progeny. It’s like cancer in another way too: it starts small, but grows through the social body it infests until that body is destroyed.

How the social justice demon influences our actions

The person who first wrote about how such schemas as the social justice demon influenced us was Fyodor Dostoevsky.

Fyodor Dostoevsky: the man who wrote about demons

He coined the term I’m using, and named one of his greatest novels after them. Writing from a rightist, patriotic, and religious perspective, he described how the introduction of Western, progressive ideas destroyed the social structure of a provincial Russian town, by shaping the behaviour of those who believed, or came to believe in them. More recently, they have entered public consciousness as memes: fragments of thought or learned procedure that travel from person to person by either deliberate communication or mimesis.

There are three qualities which, in combination, make the social justice demon so virulent. The first we’ve already discussed: it closely resembles a genuinely virtuous moral position, so statements and actions based on it can be hard to argue against, and conforming to its precepts is likely to feel good. Secondly, it’s a warrior meme. Milton’s myth has Lucifer going to war with God over a perceived injustice to angels. Other warriors for the social justice demon have fought for heaven, to rescue souls from feared damnation through attachment to the wrong beliefs

The social justice demon’s warriors fighting to get everyone to heaven

Because the social justice demon ultimately opposes knowledge of difference, and in the real world most differences are relative, it can fight on either, and frequently both sides, in any dispute. Its third quality, (which may be deduced from the previous two, and its base in pure principle), is its absolutism. The idea of incrementally approximating towards perfection, which might thus never be reached, is anathema to the demon. Imperfections must be rooted out, and the promised perfection makes the cost worthwhile

A 15th century illustration of the costs of insisting on perfection

This also means that, while the social justice demon claims to be responsive to evidence, in practice no evidence can convince it otherwise, because all evidence, and especially scientific evidence, carries a margin of uncertainty. So, it will only accept (and promote) evidence which supports its a priori view: confirmatory bias. As this involves denying knowledge of difference, the evidence it uses will tend to be skeptical.

The social justice monster in mental health

As the social justice demon offers itself as an ethical position, it makes sense to look for it in ethical discourse. In mental health, it has taken up residence in what was previously called “anti-psychiatry” and more recently the “critical” movement in psychiatry and clinical psychology. It’s not hard to find statements indicating its presence: we’ve already quoted one insisting that we deny difference between those with mental illness and those without, in terms of the signs and symptoms which denote disorder. This of course is the first demonic rule.

It is also not hard to find examples supporting the second rule. This quote is from a fringe mental health treatment group “re-evaluation counselling“.

“Mental health” oppression is the systematic suppression of discharge (their term for symptomatology) and the invalidation of people’s minds. It is the attempt to control people by enforcing standards of conduct, invalidating the discharge/re-evaluation process, categorizing people into diagnoses, pressuring them to take drugs and other harmful treatments, and punishing attempts to stand up for their liberation. The point of “mental health” oppression seems to be to oppress “mental” patients. However, it is actually to maintain the status quo by reinforcing and obscuring the functioning of other oppressions, and enforcing conformity.

‘If the authors of the diagnostic manuals are admitting that psychiatric diagnoses are not supported by evidence, then no one should be forced to accept them. If many mental health workers are openly questioning diagnosis and saying we need a different and better system, then service users and carers should be allowed to do so too.’

The authors of the diagnostic manuals are of course saying that their evidence for diagnosis has uncertainty and variability, not that is no evidence for any of them. This transformation from doubt to denial is a good sign our demon is at work, particularly when it leads to a claim of oppression: the major difference between the quotes is that here the claim is expressed implicitly.

The third rule, limitation of opportunity to ensure equal benefit, has recently had an airing in the popular media.

Despite the balancing qualifier “a tiny minority”, the message is clear: take these pills and you risk becoming a monster and ending up here

Hell: the destination for all sinners (and some medication users)

The social justice demon has two problems with pills, or indeed physical treatments of any kind. First, if they are successful, then they have been successful through modification of individual difference, which the social justice demon forbids: all such modification is “oppressive”. Secondly, physical treatments come with side effects, and side effects, however balanced with benefits, are barriers to perfection, however impossible. Hell beckons.

I’d agree this is a bit extreme for a professional position, but it can nonetheless be found in professional recommendations influenced by the “critical” movement.

Many people find that ‘antipsychotic’ medication helps make experiences such as hearing voices less intense, frequent or distressing.

It can be particularly useful at times of crisis when the experiences can feel overwhelming.

However, the drugs appear to have a general rather than a specific effect: there is little evidence that they are correcting an underlying biochemical abnormality.

There are significant risks as well as potential benefits, especially when people take medication over many years.

Prescribers need to help people to weigh up the risks and benefits of taking particular drugs or indeed taking medication at all. People need to be able to try things out and arrive at an informed choice.

Services should not pressurise people to take medication.

While measured and thoughtful, there’s no doubt that the mood music of this quote is the same as the television programme, albeit less intense. It’s worth taking a moment to dissect these superficially reasonable statements, to uncover the baleful influence of the social justice demon within them.

Consider the second and final paragraphs together. A psychotic crisis involves much more than simply having odd experiences: thought processes themselves can become incoherent and incomprehensible.

Florid psychosis written down

Imagine someone who talks to you like this (and I can assure you that some psychotic folk do). Do you know what they’re talking about? Do they? Take it from me, after they recover, they won’t be able to explain this stuff to you — they’ll struggle to remember it at all. If they say “yes”, or “no”, do we even know if it’s being directed at us, or part of the conversation we think we’re having? We also know what someone in this state is capable of

Note for animal lovers: the lions were shot for behaving like lions, and discovering humans were good eating

As stated, the final paragraph is virtue signalling, making clear that whatever the reasons, giving drugs without agreement is oppressive. The social justice demon is setting its battle lines according to its second rule: it simply cannot accept that there are individual differences that might affect capacity to consent.

The conversion of doubt to denial is also well in evidence. To read this summary, it would appear that nothing more is known about antipsychotic drugs than that they they are calming, ie sedative. This is misleading

Antipsychotic drugs have visualisable targets of action, that correspond to those areas affected by psychosis (eg frontotemporal & parietotemporal) and their side effects (eg striatum and cerebellum) as the above images show. We do not fully understand how the drugs work because our theory of schizophrenia isn’t complete, but the summary has taken this uncertainty and used it to convert our understanding of antipsychotics from a specific treatment for psychosis to something that will keep patients calm and biddable. In fact, the sedative effect of antipsychotic medications is temporary, but the summary gently introduces the idea that they are no more than “chemical coshes”. Once again, drug use has been linked to oppression, now irrespective of consent.

On the other hand, psychotherapy, especially that which aims towards an idealised human relationship, fits the social justice demon’s bill perfectly. Human relationships are universal: no differences need apply. Also, if they are perfect, then there is no difference in benefit, as benefit is distributed through relationships. We are in heaven

The social justice demon’s take on psychotherapy

When we look for the equivalent summary for professional recommendations for psychotherapy, we read

The National Institute for Health and Care Excellence (NICE) has reviewed the evidence and recommends that everyone with a diagnosis of schizophrenia should be offered talking therapy. However, most are currently unable to access it.

The most researched therapy is cognitive behaviour therapy (CBT). Trials have found that on average, people gain as much benefit from CBT as from medication.

‘Family interventions’ have also been extensively researched and many people find family meetings very helpful.

Talking therapy is very popular: demand vastly outstrips supply in the NHS.
There is an urgent need for further investment in psychological approaches to ensure that all services come up to the standard of the best, and so that people can be offered choice.

Different approaches suit different people. Not everyone finds formal psychological therapy helpful and some find it positively unhelpful. We need to respect people’s choices.
All staff need to be trained in the principles of a psychological approach as outlined in this report so that it can inform not only formal therapy but also the whole culture of services and every conversation that happens within them.

We are invited to conclude that the only reason schizophrenia isn’t being treated with psychotherapy is either lack of resources or some patients’ distaste for formality.

Compare this with the section on drugs and it’s a no-brainer

To unpick this, let’s start with the NICE (National Institute for Clinical Excellence, which evaluates treatments) guidance. What the standard states is

CBTp (Cognitive Behaviour Therapy for psychosis) in conjunction with antipsychotic medication, or on its own if medication is declined, can improve outcomes such as psychotic symptoms. It should form part of a broad‑based approach that combines different treatment options tailored to the needs of individual service users.

The meaning’s quite clear: a combination approach is best, though acceptability is important, too. (Offering any treatment that the patient won’t use is pointless).

As might be expected, given the demon’s preference for confirmatory bias, the equivalence of drugs and psychotherapy is asserted without any caveat or qualification, even though this area is highly contested

The effects of CBT may be less than small

While the effect of antipsychotics is moderate or greater

with their non-preferred studies giving different results. Entirely different standards are being used to bias decision-making towards psychotherapy, irrespective of the quality of evidence of benefit.

Lurking behind this false contrast between psychotherapy and drug therapy is the third demonic rule: access to physical therapies must be restricted as they lead to imperfect and intrinsically unequal benefits.

Exorcising the Social Justice Demon

Social justice is a good thing. We therefore need ways of deploying it in mental health that avoid invoking its demon. Two philosophers, Beauchamp and Childress, have developed a system of principled biomedical ethics which can include it. They propose four, equally important principles

Acting to respect our patients’ autonomy

Trying to do good

Avoiding doing harm

Acting with justice

And, being philosophers, are well aware that principles struggle in the real world

A principle being tormented by some philosophers

They recommend a 3-step process to connect principle to reality. First, the relevant principles must be specified in terms of the real situation: hopefully it’ll be less fiendish than that in the trolley problem. It is, however, more than likely that the principles will point in different directions: for example, drugs have intended and adverse effects. Beauchamp and Childress recommend, in their second step, to trying balance the opposing principles. Their third step is to employ dialectical reasoning to synthesise the opposing, weighted and balanced principles (for none can be ignored) into a course of action that expresses them all to the fullest extent the constraining circumstances allow. The result is what the social justice demon hates; an ethical compromise.
Compromise lacks the grandeur and purity of the heroic stance pushed by the social justice demon. However, ethical compromises are constrained to benefit their subjects. Dostoevsky reminds us that the endless battles over principle that the social justice demon promotes can destroy what was being fought over

which in our case are patients, services, scientific integrity and professional credibility. As my introduction implied, achieving social justice for our patients is a goal we should all be contributing to. However, this is one of those occasions when the best really is the enemy of the good.